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APPENDIX C

STATEMENT OF QUALIFICATIONS

REQUIRED FORMS

_____________________________________________________________________________________Community Services Block Grant RFSQ 2019 77Statement of Qualifications Required Forms

Appendix CTable of Contents

PAGE #Part I

Part II

Statement of Qualifications Checklist

Statement of Qualifications Checklist

79

80

Exhibit 1 Proposer’s Organization Questionnaire/Affidavit and CBE Information

81

Exhibit 2 Proposer’s Description of Current Operations 84

Exhibit 3 Proposer’s Plan to Provide Core Services 91

Exhibit 4 Proposer’s References 97

Exhibit 5 Proposer’s List of Contracts 99

Exhibit 6 Proposer’s List of Terminated Contracts 100

Exhibit 7 Signature Page of Master Agreement 101

Exhibit 8 Certification of No Conflict of Interest 102

Exhibit 9 Proposer’s EEO Certification 103

Exhibit 10 Familiarity with the County Lobbyist Ordinance Certification 104

Exhibit 11 Attestation of Willingness to Consider GAIN/GROW Participants 105

Exhibit 12 County of Los Angeles Contractor Employee Jury Service Program Certification Form and Application for Exception

106

Exhibit 13 Charitable Contributions Certification 107

Exhibit 14 Certification of Compliance with the County’s Defaulted Property Tax Reduction Program

108

Exhibit 15 Zero Tolerance Policy on Human Trafficking Certification 109

Exhibit 16 Compliance with Fair Chance Employment Hiring Practices Certification

110

Exhibit 17 Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tiered Covered Transactions (45 C.F.R Part 76)

111

_________________________________________________________________________________________Community Services Block Grant RFSQ 2019 78Statement of Qualifications Required Forms

APPENDIX C

Part I – Statement of Qualifications Checklist

___________________________Proposer/Agency Legal Name

Core Service Category: _____________________________________ (Enter Only One Core Service Category)

Supervisorial District: ____________________________________ (Enter Only One Supervisorial District)

Required Forms to be Completed Page

Exhibit 1 Proposer’s Organization Questionnaire/Affidavit and CBE Information ___ to___

Exhibit 2 Proposer’s Description of Current Operations ___ to___

Exhibit 3 Proposer’s Plan to Provide Core Services ___ to___

Exhibit 4 Proposer’s References ___ to___

Exhibit 5 Proposer’s List of Contracts ___ to___

Exhibit 6 Proposer’s List of Terminated Contracts ___ to___

Required Forms to be Submitted by Proposer

Attachment 1

Copy of Minutes of Proposer’s governing body meeting or Resolution Granting Authority to Submit the Statement of Qualifications and Execute the Master Agreement to the Person Signing

___ to___

Attachment 2 Proof of Insurance or Insurability ___ to___

Attachment 3 Applicable Licenses Held by Proposer ___ to___

Part II – Statement of Qualifications Checklist


APPENDIX C

___________________________Proposer/Agency Legal Name

Required Forms to be Completed PageExhibit 7 Signature Page of Master Agreement ___ to___Exhibit 8 Certification of No Conflict of Interest ___ to___Exhibit 9 Proposer’s EEO Certification ___ to___Exhibit 10 Familiarity with the County Lobbyist Ordinance Certification ___ to___Exhibit 11 Attestation of Willingness to Consider GAIN/GROW Participants ___ to___

Exhibit 12 County of Los Angeles Contractor Employee Jury Service Program Certification Form and Application for Exception ___ to___

Exhibit 13 Charitable Contributions Certification ___ to___

Exhibit 14 Certification of Compliance with the County’s Defaulted Property Tax Reduction Program ___ to___

Exhibit 15 Zero Tolerance Policy of Human Trafficking Certification ___ to___

Exhibit 16 Compliance with Fair Chance Employment Hiring Practices Certification

___ to___

Exhibit 17Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tiered Covered Transactions (45 C.F.R Part 76)

___ to___

Required Forms to be Submitted by Proposer

Attachment 4 Articles of Incorporation as Filed with Secretary of State* ___ to___

Attachment 5 Certificate of Good Standing with State of California or State of Incorporation* ___ to___

Attachment 6Conformed copy of the most recent Statement of Information as filed with the California Secretary of State listing corporate officers or members and managers*

___ to___

Attachment 7 IRS Letter Giving Tax Exempt Status* ___ to___

Attachment 8 Copy of Most Recent Filing Under Registry of Charitable Trusts* ___ to___

Attachment 9 Copies of three most current fiscal years Financial Statements ___ to___

Attachment 10 Pending Litigation and Judgments

If not applicable, Proposer shall include a statement onAttachment 10 indicating “No Pending Litigation and Judgements

___ to___

Attachment 11 Unique Entity Identified ___ to___Note: *Not required for public entities


EXHIBIT 1PROPOSER’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT AND CBE INFORMATION

Please complete, sign and date this form. The person signing the form must be authorized to sign on behalf of the Proposer and to bind the applicant in a Master Agreement.

1. Is your firm a corporation or limited liability company (LLC)? Yes No

If yes, complete:

Legal Name (found in Articles of Incorporation) ______________________________________

State ______________________________________________ Year Inc. ________________

Non-Profit Corporation Public Entity

2. If your firm is a limited partnership or a sole proprietorship, state the name of the proprietor or managing partner:

___________________________________________________________

3. A. Check the Core Service Category for this Statement of Qualifications (select only one Category)

Child & Family Development Services Domestic Violence Services

Emergency Services Employment Services

Legal Services Senior & Disabled Adult Services

B. Check the Supervisorial District to be served (Select only one District)

First Second Third

Fourth Fifth

4. Is your firm doing business under one or more DBA’s? Yes No

If yes, complete:

Name County of Registration Year became DBA

_______________________ _________________________ _________________

_______________________ _________________________ _________________

5. Is your firm wholly/majority owned by, or a subsidiary of another firm? Yes No

If yes, complete:

Name of parent firm: _____________________________________________________

State of incorporation or registration of parent firm: ______________________________


APPENDIX CEXHIBIT 1Page 1 of 3

6. Has your firm done business as other names within last five (5) years? Yes No

If yes, complete:

Name _____________________________________ Year of Name Change: ________

Name _____________________________________ Year of Name Change: ________

7. Is your firm involved in any pending acquisition or mergers, including the associated company name? Yes No If yes, provide information:

_____________________________________________________________________________

_____________________________________________________________________________

Proposer acknowledges and certifies that firm meets and will comply with all of the Minimum Qualifications stated in Section 1.4 – Proposer’s Minimum Qualifications, of this RFSQ as listed below.

1. Proposer is a non-profit corporation qualified to do business in the State of California (this includes faith-based organizations or public entities);

2. Proposer has, by the Statement of Qualifications submission date, a minimum of three (3) years’ experience within the last five (5) years providing the same or similar services as the selected Core Service Category;

3. Proposer’s Contract Manager must have, by the Statement of Qualifications submission date, two (2) years’ experience within the last five (5) years providing the same or similar services as the selected Core Service Category;

4. Proposer has, by the Statement of Qualifications submission date, two (2) years’ experience within the last five (5) years providing health and/or human services in the designated Supervisorial District;

5. Proposer has two (2) years’ experience within the last five (5) years providing services tolow-income individuals/families;

6. Proposer provided up to ten (10), but no less than eights (8) references that are familiar with the job performance and scope of work completed by the Proposer within the last five (5) years in the selected Core Service Category. Proposer has provided at least one public entity reference.

7. Proposer has the financial capacity to provide services throughout the term of the Master Agreement;

8. Proposer has designated the Core Service Category and Supervisorial District to be served;

9. Proposer completed and submitted all required Statement of Qualifications Exhibits and Attachments in the proper format as specified in Subsection 4.7 and 4.8;

10. Proposer has no record of unsatisfactory performance, lack of integrity or poor business ethics;

11. Proposer has registered on the County’s WebVen and provided their registration number; and

12. Proposer does not have unresolved questioned cost, as identified by the Auditor-Controller, in an amount over $100,000.00, that are confirmed to be disallowed costs by the contracting County department, and remain unpaid for a period of six (6) months or more from the date of disallowance, unless such disallowed costs are the subject of current good faith negotiations to



resolve the disallowed costs, in the opinion of the County.

EXHIBIT 1

PROPOSERS ORGANIZATION QUESTIONNAIRE/AFFIDAVIT AND CBE INFORMATION

I. FIRM/ORGANIZATION INFORMATION: The information requested below is for statistical purposes only. On final analysis and consideration of award, contractor/proposer will be selected without regard to race/ethnicity, color, religion, sex, national origin, age, sexual orientation or disability.

Business Structure: Sole Proprietorship Partnership Corporation Non-Profit Franchise Other (Specify) ___________________________________________________________________

Total Number of Employees (including owners):Race/Ethnic Composition of Firm. Distribute the above total number of individuals into the following categories:

Race/Ethnic Composition Owners/Partners/Associate Partners Managers Staff

Male Female Male Female Male FemaleBlack/African American Hispanic/Latino Asian or Pacific Islander American Indian Filipino White

II. PERCENTAGE OF OWNERSHIP IN FIRM: Please indicate by percentage (%) how ownership of the firm is distributed.

Black/African American

Hispanic/ Latino

Asian or Pacific Islander American Indian Filipino White

Men % % % % % %

Women % % % % % %

III. CERTIFICATION AS MINORITY, WOMEN, DISADVANTAGED, AND DISABLED VETERAN BUSINESS ENTERPRISES: If your firm is currently certified as a minority, women, disadvantaged or disabled veteran owned business enterprise by a public agency, complete the following and attach a copy of your proof of certification. (Use back of form, if necessary.)

Agency Name Minority Women Disadvantaged Disabled Veteran Other

Proposer further acknowledges that if any false, misleading, incomplete, or deceptively unresponsive statements in connection with this Statement of Qualifications are made, the Statement of Qualifications may be rejected. The evaluation and determination in this area shall be at the Director’s sole judgment and his/her judgment shall be final.

DECLARATION: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.

PROPOSER’S NAME: COUNTY WEBVEN NUMBER:

ADDRESS:

PHONE NUMBER: E-MAIL:

INTERNAL REVENUE SERVICE EMPLOYER IDENTIFICATION NUMBER:

CALIFORNIA BUSINESS LICENSE NUMBER:

PROPOSER OFFICIAL NAME AND TITLE (PRINT):

SIGNATURE DATE_________________________________________________________________________________________Community Services Block Grant RFSQ 2019 81Statement of Qualifications Required Forms



EXHIBIT 2 - PROPOSER’S DESCRIPTION OF CURRENT OPERATIONS

_______________________________________________________PROPOSER’S LEGAL NAME

Core Service Category: ___________________________ Supervisorial District: ______

The items below pertain to the Proposer’s current operations in the Supervisorial District for which it is applying. Please attach additional pages if more space is needed, but do not exceed the page limit specified in RFSQ Subsection 4.7.1. Make sure to include Proposer’s name, Exhibit and Question number on all pages.

1. Provide a detailed description of the geographic region and community served, including the cities that your agency serves in the Supervisorial District for which it is applying.

________________________________________________________________________________________Community Services Block Grant RFSQ 2019 84Statement of Qualifications Required Forms


EXHIBIT 2 - PROPOSER’S DESCRIPTION OF CURRENT OPERATIONS (CONTINUED)




2. Provide a demographic description of the population served by the Proposer, including, but not limited to: ethnicity; languages spoken; economic status; and barriers and challenges faced by the population served.







3. Provide the Proposer’s mission and a detailed description of the services currently provided by the Proposer in the Supervisorial District for which it is applying.








4. Provide a detailed description of the services provided by the Proposer during the last five years that are the same or similar to the designated Core Service Category and subservices, if applicable. Provide relevant background information such as specific dates to demonstrate the Proposer has the required experience.







5. If the selected Core Service Category is: 1) Domestic Violence, 2) Employment Services, or 3) Legal Services, please explain how Proposer meets theCategory-Specific minimum requirements. If necessary, include documentation that demonstrates the Proposers qualifications. Note: Additional documentation will not be counted in the page limit criteria.







6. Provide a detailed description of the Proposer’s experience in working with low-income families and individuals.







1. Provide a detailed description of the Proposer’s experience providing health and/or human services in the selected Supervisorial District.




EXHIBIT 3 - PROPOSER’S PLAN TO PROVIDE CORE SERVICES

___________________________________PROPOSER’S LEGAL NAME


The items below pertain to the Proposer’s plan to provide CSBG Services in the Supervisorial District for which it is applying. Please attach additional pages if more space is needed, but do not exceed the page limit specified in RFSQ Subsection 4.7.1. Make sure to include Proposer’s name, Exhibit and question number on all pages.

1. Key Staff – Provide Names, years of relevant experience and education, for Proposer’s staff that meet the minimum qualifications.



EXHIBIT 3 - PROPOSER’S PLAN TO PROVIDE CORE SERVICES (CONTINUED)




2. Provide a detailed explanation of how the Proposer plans to provide services in the selected Core Service Category and selected Supervisorial District where services will be provided.







3. List the subservice(s) for the selected Core Service Category in Part A below, and inPart B describe how the Proposer plans to provide the subservices.

Part A:List Subservices:

Part B:Describe how Proposer plans to provide each of the subservices listed in Part A:







4. Describe the approach that will be used to identify and outreach to potential CSBG participants.







5 Describe the Proposer’s record keeping system, and how it will maintain confidentiality of participant information.







6. Explain the proposers quality control procedures and how the Proposer will ensure high quality services will be provided.



EXHIBIT 4 - PROPOSER’S REFERENCES

Proposer’s Legal Name: _____________________________

List up to ten (10), but not less than eight (8) references. References should be from organizations familiar with the Proposer’s operations and where the same or similar scope of services were provided in order to verify that the Proposer meets the Minimum Qualifications. At least one reference should be from a public agency. 1. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )

Relationship # of Years

2. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )








____________________________________________________________________________________________________________Community Services Block Grant RFSQ 2019 97Statement of Qualifications Required Forms

APPENDIX CEXHIBIT 4


EXHIBIT 4 - PROPOSER’S REFERENCES (CONTINUED)

Proposer’s Legal Name: _____________________________List up to ten (10), but not less than eight (8) references. References should be from organizations familiar with the Proposer’s operations and where the same or similar scope of services were provided in order to verify that the Proposer meets the Minimum Qualifications. At least one reference should be from a public agency. 6. Name of Firm/Individual Address Contact Person Telephone # Fax # ( ) ( )











APPENDIX CEXHIBIT 4

EXHIBIT 5 - PROPOSER’S LIST OF CONTRACTS

Proposer’s Legal Name: _____________________________List of all contracts involving the Proposer’s selected Core Service for the last five (5) years. The list must include all contracts with public or government entities. A photocopy of this form may be used if necessary.1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )

Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.

2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )









APPENDIX CEXHIBIT 5

EXHIBIT 6 - PROPOSER’S LIST OF TERMINATED CONTRACTS

Proposer’s Legal Name: _____________________________List all contracts that have been terminated within the past ten (10) years (if any). Be sure to include the reason for termination. Do not include contracts that expired.


Name or Contract No. Reason for Termination:










APPENDIX CEXHIBIT 6


EXHIBIT 7

SIGNATURE PAGE OF MASTER AGREEMENT FORCOMMUNITY SERVICES BLOCK GRANT (CSBG) PROGRAM

IN WITNESS WHEREOF, the Board of Supervisors of the County of Los Angeles has

caused this Master Agreement to be executed on its behalf by the Director of the

Department of Public Social Services and approved by County Counsel, and Contractor

has caused this Master Agreement to be executed in its behalf by its duly authorized

officer, this __day of ________, 20__. The persons signing on behalf of the Contractor

warrant under penalty or perjury that he or she is authorized to bind Contractor.

COUNTY OF LOS ANGELES

By: _____________________________ Antonia Jiménez, Director

Department of Public Social Services

Date: ___________________

By_____________________________Contractor

Signature:________________________

Printed Name: ____________________

Title: __________________________

APPROVED AS TO FORM:

_____________________MARY C. WICKHAM County Counsel

By________________________ Deputy County Counsel______________________________________________________________________________Community Services Block Grant RFSQ 2019 101Statement of Qualifications Required Forms

APPENDIX CEXHIBIT 7

EXHIBIT 8

CERTIFICATION OF NO CONFLICT OF INTEREST

The Los Angeles County Code, Section 2.180.010, provides as follows:

CONTRACTS PROHIBITED

Notwithstanding any other section of this Code, the County shall not contract with, and shall reject any proposals submitted by, the persons or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract:

1. Employees of the County or of public agencies for which the Board of Supervisors is the governing body;

2. Profit-making firms or businesses in which employees described in number 1 serve as officers, principals, partners, or major shareholders;

3. Persons who, within the immediately preceding 12 months, came within the provisions of number 1, and who:

a. Were employed in positions of substantial responsibility in the area of service to be performed by the contract; or

b. Participated in any way in developing the contract or its service specifications; and

4. Profit-making firms or businesses in which the former employees, described in number 3, serve as officers, principals, partners, or major shareholders.

Contracts submitted to the Board of Supervisors for approval or ratification shall be accompanied by an assurance by the submitting department, district or agency that the provisions of this section have not been violated.

____________________________________________________Proposer Name

____________________________________________________Proposer Official Title

____________________________________________________Official’s Signature

______________________________________________________________________________Community Services Block Grant RFSQ 2019 101Statement of Qualifications Required Forms

APPENDIX CEXHIBIT 8

EXHIBIT 9

PROPOSER’S EEO CERTIFICATION

____________________________________________________________________________Proposer’s Name

____________________________________________________________________________Address

____________________________________________________________________________Internal Revenue Service Employer Identification Number

GENERAL

In accordance with provisions of the County Code of the County of Los Angeles, the Proposer certifies and agrees that all persons employed by such firm, its affiliates, subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, or sex and in compliance with all anti-discrimination laws of the United States of America and the State of California.

CERTIFICATION YES NO

1. Proposer has written policy statement prohibitingdiscrimination in all phases of employment. ( ) ( )

2. Proposer periodically conducts a self-analysis orutilization analysis of its work force. ( ) ( )

3. Proposer has a system for determining if its employmentpractices are discriminatory against protected groups. ( ) ( )

4. When areas are identified in employment practices,Proposer has a system for taking reasonable corrective action to include establishment of goal and/or timetables. ( ) ( )

___________________________________ ______________________Signature Date

______________________________________________________________________ Name and Title of Signer (please print)

______________________________________________________________________________Community Services Block Grant RFSQ 2019 101Statement of Qualifications Required Forms

APPENDIX CEXHIBIT 9

EXHIBIT 10

FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION

The Proposer certifies that:

1) It is familiar with the terms of the County of Los Angeles Lobbyist

Ordinance, Los Angeles Code Chapter 2.160;

2) That all persons acting on behalf of the organization have and will

comply with it during the proposal process; and

3) It is not on the County’s Executive Office’s List of Terminated

Registered Lobbyists.

Proposer’s Name:_____________________________

Signature:_____________________________ Date:___________________

________________________________________________________________ Name and Title of Signer (please print)

____________________________________________________________________________Community Services Block Grant RFSQ 2019 104Statement of Qualifications Required Forms

APPENDIX CEXHIBIT 10

EXHIBIT 11

ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROW PARTICIPANTS

As a threshold requirement for consideration for Master Agreement award, Proposer shall demonstrate a proven record for hiring GAIN/GROW participants or shall attest to a willingness to consider GAIN/GROW participants for any future employment opening if they meet the minimum qualifications for that opening. Additionally, Proposer shall attest to a willingness to provide employed GAIN/GROW participants access to the Proposer’s employee mentoring program, if available, to assist these individuals in obtaining permanent employment and/or promotional opportunities.

To report all job openings with job requirements to obtain qualified GAIN/GROW participants as potential employment candidates, Contractor shall email: [email protected] and [email protected].

Proposers unable to meet this requirement shall not be considered for Master Agreement award.

Proposer shall complete all of the following information, sign where indicated below, and return this form with any resumes and/or fixed price bid being submitted:

A. Proposer has a proven record of hiring GAIN/GROW participants.

______YES (subject to verification by County)______NO

B. Proposer is willing to provide DPSS with all job openings and job requirements to consider GAIN/GROW participants for any future employment openings if the GAIN/GROW participant meets the minimum qualifications for the opening. “Consider” means that Proposer is willing to interview qualified GAIN/GROW participants.

______YES ______NO

C. Proposer is willing to provide employed GAIN/GROW participants access to its employee-mentoring program, if available.

______YES ______NO ______N/A (Program not available)

Proposer Organization: _________________________________________

Signature: _________________________________________________________

Print Name: ________________________________________________________

Title:_______________________________ Date: ________________________

Telephone No.: ___________________ Fax No.: _______________________



EXHIBIT 12COUNTY OF LOS ANGELES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM

CERTIFICATION FORM AND APPLICATION FOR EXCEPTION The County’s solicitation for this Request for Statement of Qualifications is subject to the County of Los Angeles Contractor Employee Jury Service Program (Program), Los Angeles County Code, Chapter 2.203. All Proposers, whether a contractor or subcontractor, must complete this form to either certify compliance or request an exception from the Program requirements. Upon review of the submitted form, the County department will determine, in its sole discretion, whether the Proposer is given an exemption from the Program.

Company Name:Company Address:

City: State: Zip Code:

Telephone Number:

Solicitation For ____________ Services:

If you believe the Jury Service Program does not apply to your business, check the appropriate box in Part I (attach documentation to support your claim); or, complete Part II to certify compliance with the Program. Whether you complete Part I or Part II, please sign and date this form below.Part I: Jury Service Program is Not Applicable to My Business

My business does not meet the definition of “contractor,” as defined in the Program, as it has not received an aggregate sum of $50,000 or more in any 12-month period under one or more County contracts or subcontracts (this exception is not available if the contract itself will exceed $50,000). I understand that the exception will be lost and I must comply with the Program if my revenues from the County exceed an aggregate sum of $50,000 in any 12-month period.

My business is a small business as defined in the Program. It 1) has ten or fewer employees; and, 2) has annual gross revenues in the preceding twelve months which, if added to the annual amount of this contract, are $500,000 or less; and, 3) is not an affiliate or subsidiary of a business dominant in its field of operation, as defined below. I understand that the exception will be lost and I must comply with the Program if the number of employees in my business and my gross annual revenues exceed the above limits.

“Dominant in its field of operation” means having more than ten employees and annual gross revenues in the preceding twelve months, which, if added to the annual amount of the contract awarded, exceed $500,000.

“Affiliate or subsidiary of a business dominant in its field of operation” means a business which is at least 20 percent owned by a business dominant in its field of operation, or by partners, officers, directors, majority stockholders, or their equivalent, of a business dominant in that field of operation.

My business is subject to a Collective Bargaining Agreement (attach agreement) that expressly provides that it supersedes all provisions of the Program.

ORPart II: Certification of Compliance

My business has and adheres to a written policy that provides, on an annual basis, no less than five days of regular pay for actual jury service for full-time employees of the business who are also California residents, or my company will have and adhere to such a policy prior to award of the contract.

I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.

Print Name: Title:

Signature: Date:



EXHIBIT 13CHARITABLE CONTRIBUTIONS CERTIFICATION

_____________________________________________________________________Company Name

______________________________________________________________________Address

______________________________________________________________________Internal Revenue Service Employer Identification Number

______________________________________________________________________California Registry of Charitable Trusts “CT” number (if applicable)

The Nonprofit Integrity Act (SB 1262, Chapter 919) added requirements to California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act which regulates those receiving and raising charitable contributions.

Check the Certification below that is applicable to your company. Proposer or Contractor has examined its activities and determined that it does

not now receive or raise charitable contributions regulated under California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act. If Proposer engages in activities subjecting it to those laws during the term of a County contract, it will timely comply with them and provide County a copy of its initial registration with the California State Attorney General’s Registry of Charitable Trusts when filed.

OR

Proposer or Contractor is registered with the California Registry of Charitable Trusts under the CT number listed above and is in compliance with its registration and reporting requirements under California law. Attached is a copy of its most recent filing with the Registry of Charitable Trusts as required by Title 11 California Code of Regulations, sections 300-301 and Government Code sections 12585-12586.

______________________________________ ___________________Signature Date

_____________________________________________________________________Name and Title of Signer (please print)



EXHIBIT 14CERTIFICATION OF COMPLIANCE WITH THE COUNTY’SDEFAULTED PROPERTY TAX REDUCTION PROGRAM

Company Name:

Company Address:


Telephone Number: Email address:

Solicitation/Contract For ____________ Services:

The Proposer/Bidder/Contractor certifies that:

□ It is familiar with the terms of the County of Los Angeles Defaulted Property Tax Reduction Program, Los Angeles County Code Chapter 2.206; AND

To the best of its knowledge, after a reasonable inquiry, the Proposer/Bidder/Contractor is not in default, as that term is defined in Los Angeles County Code Section 2.206.020.E, on any Los Angeles County property tax obligation; AND

The Proposer/Bidder/Contractor agrees to comply with the County’s Defaulted Property Tax Reduction Program during the term of any awarded contract.

- OR -

□ I am exempt from the County of Los Angeles Defaulted Property Tax Reduction Program, pursuant to Los Angeles County Code Section 2.206.060, for the following reason:________________________________________________________________

________________________________________________________________

I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.

Print Name: Title:

Signature: Date:



EXHIBIT 15

ZERO TOLERANCE POLICY ON HUMAN TRAFFICKING CERTIFICATION

Company Name:

Company Address:



Solicitation/Contract for _______________________________ Services

PROPOSER CERTIFICATION

Los Angeles County has taken significant steps to protect victims of human trafficking by establishing a zero-tolerance policy on human trafficking that prohibits contractors found to have engaged in human trafficking from receiving contract awards or performing services under a County contract.

Proposer acknowledges and certifies compliance with Section 8.53 (Compliance with County’s Zero Tolerance Policy on Human Trafficking) of the proposed Master Agreement and agrees that proposer or a member of his staff performing work under the proposed Master Agreement will be in compliance. Proposer further acknowledges that noncompliance with the County's Zero Tolerance Policy on Human Trafficking may result in rejection of any proposal, or cancellation of any resultant Master Agreement, at the sole judgment of the County.

I declare under penalty of perjury under the laws of the State of California that the information herein is true and correct and that I am authorized to represent this company.

Print Name:

Title:

Signature: Date:



EXHIBIT 16

COMPLIANCE WITH FAIR CHANCE EMPLOYMENT HIRING PRACTICESCERTIFICATION

Company Name:

Company Address:



Solicitation/Contract for _______________________________ Services

PROPOSER/CONTRACTOR CERTIFICATION

The Los Angeles County Board of Supervisors approved a Fair Chance Employment Policy in an effort to remove job barriers for individuals with criminal records. The policy requires businesses that contract with the County to comply with fair chance employment hiring practices set forth in California Government Code Section 12952, Employment Discrimination: Conviction History (California Government Code Section 12952), effective January 1, 2018.

Proposer/Contractor acknowledges and certifies compliance with fair chance employment hiring practices set forth in California Government Code Section 12952 and agrees that proposer/contractor and staff performing work under the Contract will be in compliance. Proposer/Contractor further acknowledges that noncompliance with fair chance employment practices set forth in California Government Code Section 12952 may result in rejection of any proposal, or termination of any resultant Master Agreement, at the sole judgment of the County.

I declare under penalty of perjury under the laws of the State of California that the information herein is true and correct and that I am authorized to represent this company.

Print Name:

Title:

Signature: Date:



EXHIBIT 17CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIEREDCOVERED TRANSACTIONS (45 C.F.R. PART 76)

Instructions for Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -- Lower Tiered Covered Transactions (45 C.F.R. Part 76)

1. This certification is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that Proposer knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

2. Proposer shall provide immediate written notice to the person to whom this proposal is submitted if at any time Proposer learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

3. The terms “covered transaction,” “debarred,” “suspended,” “ineligible,” “lower tier covered transaction,” “Participant,” “person,” “primary covered transaction, “principal,” “proposal,” and “voluntarily excluded,” as used in this certification, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.

4. Proposer agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

5. Proposer further agrees by submitting this proposal that it will include the provision entitled Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion --Lower Tier Covered Transaction (45 C.F.R. Part 76),” as set forth in the text of the Sample Master Agreement attached to the Request for Statement of Qualifications, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

6. Proposer acknowledges that a participant in a covered transaction may rely upon a certification of a prospective Participant in a lower tier covered transaction that it is not proposed for debarment under 48 C.F.R. part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless itknows that the certification is erroneous.



Proposer acknowledges that a Participant may decide the methods and frequency by which it determines the eligibility of its principals. Proposer acknowledges that each Participant may, but is not required to; check the List of Parties Excluded from Federal Procurement and Non-procurement Programs.

7. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the required certification. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

8. Expert for transactions authorized under paragraph 4 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

9. Where Proposer and/or its subcontractor/Subcontractor(s) is or are unable to certify to any of the statements in this Certification, Proposer shall attach a written explanation to its proposal in lieu of submitting this Certification. Proposer’s written explanation shall describe the specific circumstances concerning the inability to certify. It further shall identify any owner, officer, partner, director, or other principal of the Proposer and/or subcontractor/Subcontractor who is currently suspended, debarred, ineligible, or excluded from securing federally funded contracts. The written explanation shall provide that person’s or those persons’ job description(s) and function(s) as they relate to the agreement which is being solicited by this Request for Statement of Qualifications.

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered transactions (45 C.F.R. Part 76)

Proposer hereby certifies that neither it nor any of its owners, officers, partners, directors, other principals or subcontractor/Subcontractors is currently debarred, suspended, proposed for debarment, declared ineligible or excluded from securing federally funded contracts by any federal department or agency.

_____________ _____________________________________Dated Signature of Authorized Representative

_____________________________________Title of Authorized Representative

_____________________________________



Printed Name of Authorized Representative


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Los Angeles County, Californiafile.lacounty.gov/SDSInter/dpss/1060956_Appendix-C... · Web viewI am exempt from the County of Los Angeles Defaulted Property Tax Reduction Program,